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Tuesday, 13 March 2012

Primary Health Care – Choosing the Best model for Canadians

The Alma Ata declaration of 1978 is a major landmark 3 – page document that deserves re-reading  Alma Ata declaration  . Alma Ata will be mostly known for the rallying call of “Health For All by the year 2000”. In addition to needing to redefine the target date there are a few other updates that might be suggested,  but the main components of the document are as relevant today 34 years later.   The foundation of subspecialites like “health promotion”, “determinants of health”, and “population health” are clearly visible in the text.  Alma Ata was predominately a call for reform of health care to ensure primary health care systems were the foundation of national health systems.  

While the document was often used to mobilize primary health care systems in underdeveloped countries (barefoot doctors), there was a subtheme for developed countries that health systems focused on secondary and tertiary care were not sustainable either.   How prophetic that vision has turned out to be.
Enlightened jurisdictions began primary health care reforms in the wake of Alma Ata.  One can argue on the relative success or failure of these efforts – but countries with more focus on primary health care tend to have more health equity and are expending less GDP than those that have invested in tertiary systems (see for example International comparisons on Determinants of Health ).  

Canada’s slow creep to reforming primary health care was in part driven by the medical profession’s realization that the proportion of medical graduates entering family practice was continuously eroding and had slipped to only 1/3rd.  The other long standing driver is the history of and contributions of community health centres and CLSC structures.
There came a series of investments in the late 90’s of the typical Canadian pilot projects, atypically followed by further investments to disseminate and implement the knowledge gained.   Perhaps not the smoothest of transitions, and since provinces could choose their reform model, the diversity was notable.  Many provinces went the route of “building” primary health care with some shining examples but minimal success in changing the whole system.  Alberta more broadly stimulated joint ventures between physicians and health regions with mixed success.  Ontario stimulated physician to reform through “incentivizing” and supporting expansion of an already robust community health centre infrastucture.  

Here we are some 15 years into the primary health care reform process and the volume of information gained on what works and what doesn’t is deafening.  Or, perhaps we just can’t hear it. Or, perhaps it wasn’t well evaluated, or.......etc.      CIHI was supposed to lead the evaluation, and that toppled in the early 2000’s with hardly a peep , does anybody know what happened? The lack of formal evaluations is appalling to say the least given the hundreds of millions invested, it rivals regional health authority reforms in bureaucractic decision making without rigorous evaluations.  

At last, something concrete, although perhaps biased.   From the Institute for Clinical Evaluation Studies in Toronto www.ices.on.ca  comes a comparative analysis based on the multiple primary care models[i] that co-exist in Ontario.  The problem is the study was commissioned by the Association of Ontario Health Centres and some of the measures used are not as forthcoming in openly comparing the different models. The long list of limitations of the data speak to some of the assumptions and problems.  CHC enrollees represent only 1% of the provincial residents. The presented data strongly support CHCs as a preferred model of care.

However, at last something that uses the wealth of administrative data sets to do comparisons of persons using the various different models.    There is a reasonable  set of references that can be accessed with additional recent comparative statistics.   Watch for the peer reviewed materials, but there is finally some progress on trying to answer the question of how to improve the primary care system in Canada ICES comparison of primary care models.   

[i] Purists can argue for days on the differences between primary health care and primary care.   The two are intertwined and reform in one cannot proceed without the other.   

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